COLEGIO SAN AGUSTIN-BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

P.O. Box 120, B.S. Aquino Drive,
Bacolod City, 6100 Philippines
Tel. No. (034) 434-2471/ (034) 434-7887
CSA-B Website: www.csab.edu.ph

NURSING PROGRAM

PERFORMANCE EVALUATION TOOL

SURGICAL NURSING

Name of Student: _________________________________________________

SURGICAL NURSING COMPETENCIES DESIRED 1ST 2ND 3RD 4TH

RATING RLE RLE RLE RLE
DATE
AREA
TOTAL No. OF HOURS
LEVEL
SEMESTER
ACADEMIC YEAR
I. SAFE AND QUALITY NURSING CARE
1. Demonstrates knowledge based on health status of the client.
a. Iden es correctly the signs and symptoms of pa ent’s 1
disease condi on.
b. Iden es the predisposing and precipita ng factors of 1
pa ent’s disease condi on.
c. Di eren ates normal laboratory results from devia ons 1
d. Discusses comprehensively the pathophysiology of pa ent’s 1
disease condi on.
e. Discusses the pa ent’s surgical nursing management. 1
2. Provides sound decision making in caring for surgical pa ents.
a. formulates appropriate nursing diagnosis 1
b. Priori es iden ed nursing problems 1
c. Formulates an appropriate nursing care plan 1
d. Explains ra onale of the nursing ac on 1
3. Promotes safety and comfort measures in all aspects of care 1
4. maintains privacy in all aspects of clients care 1
5. Provides nursing care based on client’s needs
a. Performs nursing procedures e ec vely 1
6. Administers medica on and other health therapeu cs adhering 1
to the 10 rights
a. Prepares and administers medica ons accurately 1
b. Formulates a comprehensive drug study and discusses its 1
ac ons, side e ects and nursing considera on

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 c. Observes and monitors for drug related reac ons 1

d. Demonstrates correct IV/drug calcula ons and safe dosage 1
e. Documents accurately any drug related reac ons 1
7. U lizes the nursing process in the care of surgical clients
a. Obtains a comprehensive surgical history through interview, 1
pa ent’s chart, signi cant others and member of the health team
b. Performs a thorough nursing assessment u lizing the di erent 1
approaches (System Approach, Cephalo-caudal and Gordon’s
Func onal Assessment)
c. U lizes IPPA technique in conduc ng physical assessment 1
d. Formulates a comprehensive individualized nursing care plan 1
e. Implements planned nursing care based on expected outcomes 1
f. Evaluates e ec veness of nursing interven ons rendered 1
g. Revises nursing care plan based on expected outcome 1
h. Formulates a comprehensive discharge plan 1
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
1. Organizes work load to facilitate mely pa ent care. 1
2. Selects and u lizes appropriate hospital resources 1
3. Maintains a safe environment by adhering to proper waste 1
disposal and segrega on
4.Plans the performance of nursing ac vi es based on priori es 1
5. Performs procedures adhering to infec on control 1
6. Checks the proper func oning of equipment 1
7. Reports malfunc oning of equipment to the CI/sta 1
III.HEALTH EDUCATION (HE)
1. Conducts health teaching with regard to safety measures,
preven on of complica on and comfort measures during 1
hospitaliza on
2. Conducts health teaching as to proper nutri on, 1
ac vity/exercise, hygiene, lifestyle modi ca on, compliance to
medica on, follow-up visit, signs and symptoms of relapse
3. Conducts health teaching based on the client’s level of 1
Understanding
4. Explains accurately to the client the purpose of nursing ac on 1
IV.LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and standard opera ng procedures of the 1
hospital agency
2. Performs nursing procedures in accordance to the standards of 1
the nursing prac ce
3. Secures waiver of responsibility for refusal to undergo 1
treatment or secure informed consent
V.ETHICO-MORAL RESPONSIBILTY (EMR)
1. Respects the rights of the pa ents 1
2. Keeps con den al all the informa on obtained from the client 1
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 3. Performs nursing procedures adhering to the Code of Ethics for 1

Nurses
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Establishes rapport with the personnel, clients and family, 1
groupmates and clinical instructor
2. Demonstrates emo onal maturity and shows tac ulness in 1
dealing with clients and signi cant others
3. Reports to duty on me 1
4. Dresses appropriately and well-groomed 1
5. Maintains proper conduct and decorum at all mes 1
6. Complies with RLE requirements on me and with complete 1
Paraphernalia
VII. QUALITY IMPROVEMENT (QI)
1. Par cipates in quality improvement ac vi es related to 1
preven on of complica ons
2. Reports signi cant changes to pa ent’s condi on to CI and 1
sta nurses
3. Solicits feedback from client and signi cant others regarding 1
care rendered
4. Performs daily check of the unit and client’s progress 1
5. Provides appropriate sugges ons on correc ve and preven ve 1
measures on client’s care
VIII. RESEARCH (R)
1. Iden es researchable problem related to surgical nursing 1
2. Conducts a case study with regards to pa ent’s condi on 1
3. Conducts research works on the current trends in surgical 1
Nursing
4. Conducts an interac ve case discussion 1
IX.RECORDS MANAGEMENT
1. Maintains comprehensive and accurate documenta on of the 1
pa ent’s condi on
2. Observe protocol in disposing client’s informa on 1
3. Maintains an organized system of ling and keeping client’s 1
Record
X. COMMUNICATION (Comm)
1.Listens a en vely to pa ent’s verbaliza on of concerns, 1
thoughts and feelings
2. U lizes therapeu c communica on in the care of pa ents 1
3. Maintains client’s trust and con dence 1
4. Interprets and validates client’s body language and facial 1
Expression
5. U lizes informa cs to support the delivery of care 1
XI. COLLABORATION AND TEAMWORK (CTM)
1. Collaborates plan of care with other members of the health 1
Team
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 2. Par cipates ac vely in pa ent’s care management 1

3. Respects the role of other members of the health team in the 1
care of pa ents
4. Communicates ndings of assessment to all concerned 1
TOTAL SCORE 70

First Graded RLE : Academic Year __________ 1st Sem____ 2nd Sem____ Summer _____

_________________________________ _________________________________
Clinical Instructor’s Signature/Date Student’s Signature/Date

Second Graded RLE : Academic Year __________ 1st Sem____ 2nd Sem____ Summer _____

________________________________ _________________________________
Clinical Instructor’s Signature/Date Student’s Signature/Date

Third Graded RLE : Academic Year __________ 1st Sem____ 2nd Sem____ Summer _____

________________________________ _________________________________
Clinical Instructor’s Signature/Date Student’s Signature/Date

Fourth Graded RLE : Academic Year __________ 1st Sem____ 2nd Sem____ Summer _____

________________________________ _________________________________
Clinical Instructor’s Signature/Date Student’s Signature/Date

GRADING SYSTEM:

WRITTEN REQUIREMENTS:

Objec ves 10 points

Drug Study 30 points
Problem List 30 points
NCP 50 points
Discharge Plan 30 points
Journal 10 points
________
160 points = Equivalent x 80%

Post test and Skills lab quiz: Scores = Equivalent x 20%

_______
100%

RLE GRADE:
Wri en requirements + Post Test/Skills Lab x 50%
Performance Ra ng (PEC): Scores = Equivalent x 50%
_________
RLE GRADE - 100%

IF WITH SURGICAL CASE STUDY:

RLE GRADE x 80%
Case Study (Equivalent) x 20%
_________
FINAL RLE GRADE - 100%













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